When it comes to advanced airways, EMS education has been focusing on how we teach our students the skills needed to obtain and maintain proficiency in advanced airway placement. But even as research and debate about the best methods to obtain an advanced airway in the prehospital environment continue, there’s no disagreement that the advanced airway must be maintained and monitored once obtained.
The National Registry of EMT's paramedic psychomotor testing sheet's single line—“Secures device or confirms that the device remains properly secured”(1)—does not do justice to this important skill. Whether using a commercially available device or some other successful method to hold the airway in place, advanced airway management must be combined with patient packaging to ensure the device is truly secure. Giving your students different options and techniques to meet their patients’ unique needs will better prepare them for this challenge in the field.
Understanding the Issues
As educators, our focus has always been on developing our student’s airway placement psychomotor skills. But although we strive to make sure the airway is properly placed in the initial insertion, we must also make sure to prevent displacing the advanced airway and continue monitoring that placement. An American Society of Anesthesiology study places unrecognized tube dislodgment during the operation and transfer or movement by the patient in the same damaging event category as an unrecognized esophageal intubation.(2) Since we must move and transfer all of our patients, teaching prevention and monitoring is essential.
For years, providers have been taught to secure the advanced airway at the level of the lips. However, we now know that movement of the patient’s head, neck and even the upper body can cause movement at the distal end of the airway. This is especially true in the pediatric population where we have a limited use of cuffed tubes and limited available commercial restraint devices. An educated and skilled provider who continues to focus on the airway after initial placement and then properly documents the care is essential in preventing this potentially deadly event.
It’s Our Airway
Many providers believe (and are taught) that the advanced airway is their personal responsibility. When talking about the advanced airway after the call, for example, we hear it described in a personal manor: “My tube was good.” When teaching a provider the confidence needed to perform intubation, this possessive attitude is useful and helpful to successfully place the device. However, anytime an advanced airway is used, it’s part of a team resuscitative effort and securing, monitoring and maintaining the advanced airway needs to be taught as such. Make this point with students by explaining that an unrecognized displaced airway would not be looked on by quality review as an individual issue.
Monitoring many of the clinical findings around the advanced airway may be the purview of the advanced provider, but educating BLS providers to prevent movement and report possible displacement is a way for them to contribute to patient care. For example, teaching BLS providers that a cervical collar and a cervical immobilization device may be needed on a medical patient will allow them to anticipate and plan for it as part of packaging and moving the patient. Currently, however, many systems teach BLS providers to assist with the securing of the airway and some of the basic clinical indications of a displaced airway. This doesn't relieve the advanced provider of their responsibility for the airway. Rather, teaching these skills allows more providers to monitor the airway.
When educators first teach a new paramedic student the skill of advanced airway insertion, much of the focus is on the skill of proper and successful placement of the airway device and confirmation of correct placement. Once the student verbalizes and demonstrates all the proper confirmation techniques, simply verbalizing how the airway would be secured is all that is required for the skill to be considered complete.
Instead, we need to emphasize the actual securing of the advanced airway from the outset. This can be done by splitting the psychomotor skill into two equally important parts: First, the placement and confirmation of the airway as we always have done, and second, the securing of the airway to prevent movement of the proximal and distal ends. This involves a technique to secure the airway at the patient’s lips as well as limiting movement of the neck and upper body.
In conjunction with securing the airway, a system to monitor the airway must also be demonstrated. Preferably the student would use the objective method of constant monitoring of end-tidal carbon dioxide (EtCO2) via waveform capnography that will document the status for the airway throughout prehospital care. If not available (or there are technical issues), then a set number of well-taught subjective techniques (i.e., lung sounds, absent epigastic sounds, fogging of the tube, etc.) needs to be performed. It must be stressed to students that these must be performed at regular intervals. Stressing reassessment after any move, on arrival and especially after transfer of care will serve as proof that the providers have delivered a patient with a well-placed advanced airway.
Finally, the most neglected step is the documentation of the airway assessments. Confirmation of EtCO2 via waveform capnography after placement, following any movement or transfer, combined with a trend summary, is solid objective proof of the patency of the airway. If subjective methods are used, then initial assessment and all reassessments need to be clearly documented in the patient’s chart. Teaching our students this documentation is critical if the status of the airway they maintained is ever questioned.
Store-Bought or Do it Yourself
After confirming proper placement and noting the depth of the airway, the next step your student should take is securing the proximal end of the airway at the lips. Many services are using commercially available devices, while many others still use time-tested handmade restraints to perform this function. A study done in Pennsylvania shows only 2.3% of patients with commercial devices had displacement, while other methods showed 4.5% for face tape, 4.4% for neck tape (tape wrapped around the neck), 3.3% for those using oxygen or IV tubing, and no displacements for twill or umbilical tape. It should be noted that manually stabilizing the airway was found to have the highest rate of dislodgement at 12.5%.(3)
Regardless of your preferred or required method of restraint, be certain that it's done securely to hold the airway in place. Also, no matter what method you use, show your students at least one other method so they have additional skills available to them.
Don’t Forget the Bottom
Once your student has secured the proximal end of the advanced airway, the work is only halfway done. Flexion and extension of the neck has been proved to cause movement of the distal tip of an endotracheal tube, especially in children.(4) Therefore, a properly sized cervical collar should be placed on all patients with an advanced airway. If the patient doesn't fit in a commercially available collar, teach the students to use towel rolls with tape or other alternative methods to limit cervical movement. Upper body movement should also be restricted within the limits allowed by the patient’s clinical presentation. An intubated congestive heart failure patient being transported in a semi-Fowler’s position can also be well secured to the cot to limit movement.
For those using high-fidelity simulators, certain models record patient’s neck movement during simulation. You could use this feature during the advanced airway insertion to monitor movement, but also after insertion to monitor how well the team does at limiting movements that could cause airway displacement.
An unrecognized advanced airway displacement is one of the most devastating events a critically ill or injured patient can suffer. Teaching our students to properly restrain the airway and limit neck and body movement every time they practice the skill is essential. Combining these skills with proper monitoring and documentation ensures the best possible outcome for our patients, and protect themselves from a potentially devastating clinical error. As educators, we can improve this important part of airway management.
1. National Registry of Emergency Medical Technicians advanced level psychomotor examination: Supraglottic airway device. Retrieved on May 31, 2013, from www.nremt.org/nremt/downloads/P304%20NREMT.pdf.
2. Tinker JH, Dull DL, Caplan RA, et al. Role of monitoring devices in prevention of anesthetic mishaps: A closed claims analysis. Anesthesiology. 1989;71(4):541–546.
3. Kupas DF, Kauffman KF, Wang HE. Effect of airway-securing method on prehospital endotracheal tube dislodgment. Prehosp Emerg Care. 2010;14(1):26–30.
4. Weiss M, Knirsch W, Kretschmar O, et al. Tracheal tube-tip displacement in children during head-neck movement: A radiological assessment. Br J Anaesth. 2006;96(4):486–491.